JP7308190B2 - Treatment of ovarian cancer with anti-CD47 and anti-PD-L1 - Google Patents

Description

CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of U.S. Provisional Application No. 62/574,073, filed October 18, 2017, which is incorporated herein by reference in its entirety for all purposes. incorporated.

SEQUENCE LISTING This application contains a Sequence Listing which has been submitted electronically in ASCII format and is hereby incorporated by reference in its entirety. The aforementioned ASCII copy, created on Sep. 26, 2018, is 41404WO_CRF_sequencelisting. txt and is 12,403 bytes in size.

Ovarian cancer is the most frequent cause of death from gynecologic cancer in the United States. Standard systemic therapy for patients with newly diagnosed advanced disease usually involves the use of platinum-based chemotherapy with or without antiangiogenic agents. Recently, targeted agents such as PARP inhibitors have been utilized in women with advanced disease and BRCA mutations. However, newer immunotherapies such as checkpoint inhibitors have not impacted clinical outcomes sufficiently to become standard treatment. In women with recurrent ovarian cancer, the platinum-free interval (PFI), defined as the interval between the last platinum dose and the date of recurrence, strongly correlates with the likelihood of subsequent chemotherapy response. Patients with PFI greater than or equal to less than 6 months were historically termed platinum-resistant, and these patients had limited treatment options. Therefore, the development of effective cancer therapies for these patients would address a substantial unmet medical need.

The immune system's natural ability to detect and destroy abnormal cells may prevent the development of many cancers. However, cancer cells may be able to evade detection and destruction by the immune system. Do cancer cells have reduced expression of tumor antigens on their surface, making them difficult to detect by the immune system; do they express proteins on their surface that induce immune cell inactivation; and/ or induce cells in the microenvironment to release substances that suppress immune responses and promote tumor cell proliferation and survival.

Cancer immunotherapy has been developed to enhance the immune response to tumors by stimulating specific components of the immune system; or by counteracting signals produced by cancer cells that suppress the immune response. .

One approach blocks immune checkpoint proteins to limit the strength and duration of the immune response. These proteins normally keep the immune response in check by preventing an overly strong response that can damage normal and abnormal cells. Blocking the activity of immune checkpoint proteins releases the "brakes" of the immune system, increasing its ability to destroy cancer cells.

Immune checkpoint inhibitors in current clinical use include ipilimumab, which blocks the activity of CTLA4 expressed on the surface of activated cytotoxic T lymphocytes. CTLA4 functions as a "switch" that inactivates these T cells, thereby reducing the strength of the immune response; its inhibition increases cytotoxic T cell responses. Two other FDA-approved checkpoint inhibitors, nivolumab and pembrolizumab, function similarly but target PD-1. Avelumab, a third FDA-approved checkpoint inhibitor, targets PD-L1.

Other forms of immunotherapy typically use proteins that regulate or help regulate immune system activity to enhance the body's immune response to cancer, such as interleukins and interferons. Antibodies that target tumor cell antigens are also in clinical use.

Some forms of immunotherapy take advantage of the innate immune system. Engagement of the cell surface protein CD47 and the phagocytic receptor SIRPalpha on healthy cells can turn off engulfment mediated by multiple modalities, including apoptotic cell clearance and FcR-mediated phagocytosis, an important 'don' t eat-me)” signal. Blocking SIRPalpha's engagement with CD47-mediated phagocytic cells, or loss of CD47 expression in knockout mice, can eliminate viable and non-senescent erythrocytes. Alternatively, blocking SIRPalpha recognition can also allow targets that are not normally phagocytosed to be engulfed. It has also been shown that anti-CD47 antibody treatment not only allows macrophage phagocytosis of cancer, but can initiate an anti-tumor cytotoxic T-cell immune response.

Combining an immunomodulatory agent with CD47 blockade may also enhance the efficacy of the immunomodulatory agent by promoting tumor antigen presentation and depletion of suppressive immune cells. This allows for shorter treatment durations, thereby reducing the duration and severity of potential toxicity and side effects.

Related publications include "Engineered Sirp alpha Variants Asm Immunotherapeutic Adjuvants To Anticancer Antibodies". Science 341(6141):88-91; Willingham, S.; B. , J. P. Volkmer, Et Al. (2012). "The Cd47-Signal Regulatory Protein Alpha (Sirpa) Interaction Is A Therapeutic Target For Human Solid Tumors". Proc Natl Acad Sci USA 109(17):6662-6667 (Non-Patent Document 2). Chao, M.; P. , A. A. Alizadeh, Et Al. (2010). "Anti-Cd47 Antibody Synergizes With Rituximab To Promote Phagocytosis And Eradicate Non-Hodgkin Lymphoma". Cell 142(5):699-713 (Non-Patent Document 3). Boyerinas B, Jochems C, Fantini M, Heery CR, Gulley JL, Tsang, KY, and Schlom J.; Antibody-Dependent Cellular Cytotoxicity Activity of a Novel Anti-PD-L1 Antibody Avelumab (MSB0010718C) on Human Tumor Cells Cancer Immunol Res 20 15;3(10):1148-57 (non-patent document 4). Davis A, Tinker AV, Friedlander M.; "Platinum resistant" ovarian cancer: What is it, who to treat and how to measure benefit? Gynecol Oncol 2014;133:624-631 (Non-Patent Document 5). Disis ML, Patel MR, Pant S, Hamilton EP, Lockart AC, Kelly K, Beck JT, Gordon MS, Weiss, GJ, Taylor MH, Chaves J, Mita AC, Chin KM, von Heydebreck A,, Cuillerot J -M, Gulley JL. Avelumab (MSB0010718C; anti-PD-L1) in patients with recurrent/refractory ovarian cancer from the JAVELIN Solid Tumor phase 1b trial: Safety and clinical activity y. J Clin Oncol 34, 2016 (suppl; abstr 5533) (Non-Patent Document 6). Rustin GJS, Vergote I, Eisenhauer E, et al. Definitions for Response and Progression in Ovarian Cancer Clinical Trials Incorporating RECIST 1.1 and CA 125 Agreed by the Gynecological Cancer Intergroup (GCIG). Int J Gynecol Cancer 2011;21:419-423 (Non-Patent Document 7). Seymour L, Bogaerts J, Perrone A, et al. RECIST working group. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics. Lancet Oncol. 2017 Mar;18(3):e143-e152 (Non-Patent Document 8). Tseng D, Volkmer JP, Willingham SB, et al. , Anti-CD47 antibody-mediated phagocytosis of cancer by macrophages primes an effective antibody. PNAS 2013; 110(27): 11103-11108 (Non-Patent Document 9). Wilson MK 1, Pujade-Lauraine E, Aoki D, et al. Fifth Ovarian Cancer Consensus Conference of the Gynecologic Cancer InterGroup: recent disease. Annals of Oncol 2017;28:727-732 (Non-Patent Document 10). Yanagita T, Murata Y, Tanaka D, et al, Anti-SIRP antibodies as a potential new tool for cancer immunotherapy. JCI Insight, 2017;2(1):e89140 (Non-Patent Document 11). Related applications include: Methods for Achieving Therapeutically Effective Doses of anti-CD47 Agents for Treating Cancer, US Pat. No. 9,623,079. Treatment of cancer with combinations of immunoregulatory agents, US Patent Application Publication No. 15/411,623, each of which is hereby incorporated by reference in its entirety for all purposes.

U.S. Patent No. 9,623,079 U.S. Patent Application Publication No. 15/411,623

"Engineered Sirp alpha Variants Asm Immunotherapeutic Adjuvants To Anticancer Antibodies". Science 341(6141):88-91 Willingham, S.; B. , J. P. Volkmer, Et Al. (2012). "The Cd47-Signal Regulatory Protein Alpha (Sirpa) Interaction Is A Therapeutic Target For Human Solid Tumors". Proc Natl Acad Sci USA 109(17):6662-6667 Chao, M.; P. , A. A. Alizadeh, Et Al. (2010). "Anti-Cd47 Antibody Synergizes With Rituximab To Promote Phagocytosis And Eradicate Non-Hodgkin Lymphoma". Cell 142(5):699-713 Boyerinas B, Jochems C, Fantini M, Heery CR, Gulley JL, Tsang, KY, and Schlom J.; Antibody-Dependent Cellular Cytotoxicity Activity of a Novel Anti-PD-L1 Antibody Avelumab (MSB0010718C) on Human Tumor Cells Cancer Immunol Res 20 15;3(10):1148-57 Davis A, Tinker AV, Friedlander M.; "Platinum resistant" ovarian cancer: What is it, who to treat and how to measure benefit? Gynecol Oncol 2014;133:624-631 Disis ML, Patel MR, Pant S, Hamilton EP, Lockart AC, Kelly K, Beck JT, Gordon MS, Weiss, GJ, Taylor MH, Chaves J, Mita AC, Chin KM, von Heydebreck A,, Cuillerot J -M, Gulley JL. Avelumab (MSB0010718C; anti-PD-L1) in patients with recurrent/refractory ovarian cancer from the JAVELIN Solid Tumor phase 1b trial: Safety and clinical activity y. J Clin Oncol 34, 2016 (suppl; abstr 5533) Rustin GJS, Vergote I, Eisenhauer E, et al. Definitions for Response and Progression in Ovarian Cancer Clinical Trials Incorporating RECIST 1.1 and CA 125 Agreed by the Gynecological Cancer Intergroup (GCIG). Int J Gynecol Cancer 2011;21:419-423 Seymour L, Bogaerts J, Perrone A, et al. RECIST working group. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics. Lancet Oncol. 2017 Mar;18(3):e143-e152 Tseng D, Volkmer JP, Willingham SB, et al. , Anti-CD47 antibody-mediated phagocytosis of cancer by macrophages primes an effective antibody. PNAS 2013;110(27):11103-11108 Wilson MK 1, Pujade-Lauraine E, Aoki D, et al. Fifth Ovarian Cancer Consensus Conference of the Gynecologic Cancer InterGroup: recent disease. Annals of Oncol 2017;28:727-732 Yanagita T, Murata Y, Tanaka D, et al, Anti-SIRP antibodies as a potential new tool for cancer immunotherapy. JCI Insight, 2017;2(1):e89140

SUMMARY Methods are provided for treating an individual, eg, a human subject, with a therapeutic combination of an anti-CD47 antibody and an anti-PD-L1 antibody. An advantage of the present invention is that, as a single immunomodulatory agent, or a combination of immunomodulatory agents, lower doses of drugs, such as anti-CD47 antibodies and It may be the use of PD-L1 antibodies. An advantage of the present invention is also, or alternatively, that as a single immunomodulatory agent, or a combination of immunomodulatory agents, the length of time required for treatment compared to the length of time required for treatment in the absence of CD47 blockade It can also be a reduction in the length of time. An advantage of the present invention may also, or alternatively, be an enhanced response compared to that observed after treatment with a single immunomodulatory agent or combination of immunomodulatory agents in the absence of CD47 blockade.

The methods of the invention involve administration of anti-CD47 antibodies. In some embodiments, the antibody comprises a human IgG4 Fc region. In some embodiments, the anti-CD47 antibody competes with Hu5F9-G4 for binding to CD47. In some embodiments, the anti-CD47 antibody binds to the same CD47 epitope as Hu5F9-G4. In other embodiments, the anti-CD47 antibody is Hu5F9-G4.

The methods of the invention involve administration of anti-PD-L1 antibodies. In some embodiments, the anti-PD-L1 antibody is Avelumab (Bavencio®).

In some embodiments, the anti-CD47 antibody is Hu5F9-G4 and the anti-PD-L1 antibody is Avelumab (Bavencio®).

In some embodiments, the ovarian cancer is epithelial ovarian cancer, optionally serous tumor, mucinous tumor, clear cell tumor, endometrioid tumor, transitional cell tumor, Brenner's tumor, carcinosarcoma tumor , mixed epithelial tumor, borderline epithelial tumor, undifferentiated carcinoma tumor, fallopian tube tumor, or primary peritoneal tumor. In some embodiments, the epithelial ovarian cancer is a serous tumor, eg, the serous tumor ovarian cancer is low grade or high grade as determined by histological analysis subclassification. In some embodiments, tumor type is determined by histological analysis.

In some embodiments, the subject is a naive anti-PD-L1 antibody. The subject may be platinum sensitive or platinum resistant.

Methods of the invention include administration of anti-CD47 and/or anti-PD-L1 antibodies by any suitable delivery. In some embodiments, the anti-CD47 antibody and/or anti-PD-L1 antibody is administered intraperitoneally. In some embodiments, the anti-CD47 antibody and/or anti-PD-L1 antibody is administered intratumorally. In some embodiments, the anti-CD47 antibody and/or anti-PD-L1 antibody is administered intravenously. The anti-CD47 antibody and anti-PD-L1 antibody may be administered simultaneously or sequentially.

In some embodiments of the invention, administration of an anti-CD47 antibody and/or an anti-PD-L1 antibody, compared to baseline; CA125, HE4 (human epididymal protein 4), CA-72-4, It reduces the levels of cancer markers such as CA-19-9 and CEA. In some embodiments, administration of anti-CD47 antibody and/or anti-PD-L1 antibody reduces CA125 in the subject compared to baseline. In some embodiments, the level of CA125 is measured about once a month. In other embodiments, administration reduces the level of CA125 in the subject by at least 30-90, 40-80, 50-70, 30, 40, 50, 60, 70, 80, or 90% compared to baseline. Lower. In other embodiments, administering decreases the size of the cancer or its metastases, optionally as measured by imaging, compared to baseline, optionally the imaging is CT/PET/CT or MRI. Yes, optionally including disease that initially increases in size from baseline but then decreases.

In some embodiments, the therapeutic regimen for the treatment of cancer comprises administering a loading dose of an anti-CD47 antibody, including but not limited to 5F9-G4, wherein the loading dose is between 20 mg/kg and 67 mg/kg. and may be administered twice weekly at doses of 20 mg/kg to 30 mg/kg. Patients are then administered weekly or semi-weekly maintenance doses at doses of 10 mg/kg to 40 mg/kg; and may be doses of 20 mg/kg to 30 mg/kg. In some such embodiments, the cancer is ovarian cancer. In some such embodiments, the cancer is epithelial ovarian cancer, e.g., serous tumor, mucinous tumor, clear cell tumor, endometrioid tumor, transitional cell tumor, Brenner tumor, carcinosarcoma tumor, mixed epithelial Tumor, borderline epithelial tumor, undifferentiated carcinoma tumor, fallopian tube tumor, or primary peritoneal tumor.

In some embodiments, the therapeutically effective amount of anti-PD-L1 antibody is 10 mg/kg. In some embodiments, the anti-PD-L1 antibody is administered every 14 days. In some embodiments, the anti-PD-L1 antibody is administered 7 days after the priming dose and every 14 days thereafter. In some embodiments, the anti-PD-L1 antibody is administered on the same day as the priming dose and every 14 days thereafter.

The invention also includes compositions comprising anti-CD47 antibodies and anti-PD-L1 antibodies. The invention also provides kits comprising an anti-CD47 antibody, an anti-PD-L1 antibody, and instructions for use.
In certain embodiments, for example, the following are provided:
(Item 1)
A method of treating a human subject with epithelial ovarian cancer comprising:
(a) administering a priming dose of Hu5F9-G4 antibody to said subject, wherein said priming dose is 1 mg/kg of Hu5F9-G4 antibody; and
(b) administering to said subject a therapeutically effective dose of Hu5F9-G4 antibody, wherein said therapeutically effective dose of Hu5F9-G4 antibody is 20-60 mg/kg, and step (b) is at least about 7 days after initiation of (a) and every 7 days thereafter; and
(c) administering avelumab to said subject, wherein the dose of avelumab is 10 mg/kg, and step (c) is performed at least about 7 days after step (a) and every 14 days thereafter.
The above method, comprising
(Item 2)
A method of treating a human subject with epithelial ovarian cancer comprising:
(a) administering a priming dose of Hu5F9-G4 antibody to said subject, wherein said priming dose is 1 mg/kg of Hu5F9-G4 antibody; and
(b) administering to said subject a therapeutically effective dose of Hu5F9-G4 antibody, said therapeutically effective dose of Hu5F9-G4 antibody being 30 mg/kg, step (b) comprising step (a) ) at least about 7 days after initiation and every 7 days thereafter; and
(c) administering avelumab to said subject, wherein the dose of avelumab is 10 mg/kg, and step (c) is performed at least about 7 days after step (a) and every 14 days thereafter.
The above method, comprising
(Item 3)
A method of treating a human subject with ovarian cancer or reducing the size of ovarian cancer in said subject comprising: an anti-CD47 antibody in a therapeutically effective amount for said subject; and an amount therapeutically effective in said subject. administering at least one anti-PD-L1 antibody of
(Item 4)
said ovarian cancer is epithelial ovarian cancer, optionally serous tumor, mucinous tumor, clear cell tumor, endometrioid tumor, transitional cell tumor, Brenner's tumor, carcinosarcoma tumor, mixed epithelial tumor, borderline epithelium 4. The method of item 3, which is a tumor, an undifferentiated carcinoma tumor, a fallopian tube tumor, or a primary peritoneal tumor.
(Item 5)
5. The method of item 4, wherein said epithelial ovarian cancer is a serous tumor.
(Item 6)
6. The method of item 5, wherein the serous tumor ovarian cancer is low grade or high grade as determined by histological analysis subdivision.
(Item 7)
A method according to any one of the preceding items, wherein the tumor type is determined by histological analysis.
(Item 8)
The method of any one of the preceding items, wherein the subject is anti-PD-L1 antibody naive.
(Item 9)
A method according to any one of the preceding items, wherein said anti-CD47 antibody and said anti-PD-L1 antibody are administered simultaneously or sequentially.
(Item 10)
A method according to any one of the preceding items, wherein said anti-CD47 antibody comprises IgG4 Fc.
(Item 11)
The method of any one of the preceding items, wherein said anti-CD47 antibody competes with Hu5F9-G4 for binding to CD47.
(Item 12)
The method of any one of the preceding items, wherein said anti-CD47 binds to the same CD47 epitope as Hu5F9-G4.
(Item 13)
A method according to any one of the preceding items, wherein said anti-CD47 antibody is Hu5F9-G4.
(Item 14)
A method according to any one of the preceding items, wherein said anti-PD-L1 antibody is avelumab (Bavencio®).
(Item 15)
The method of any one of the preceding items, wherein said anti-CD47 antibody is Hu5F9-G4 and said anti-PD-L1 antibody is avelumab (Bavencio®).
(Item 16)
3. The method of any one of the preceding items, wherein said anti-CD47 antibody and said anti-PD-L1 antibody are each formulated as a pharmaceutical composition with a pharmaceutically acceptable excipient.
(Item 17)
12. The method of any one of the preceding items, wherein the human subject is platinum sensitive.
(Item 18)
16. The method of any one of the preceding items, except item 15, wherein said human subject is platinum resistant.
(Item 19)
A method according to any one of the preceding items, wherein said anti-CD47 antibody and/or said anti-PD-L1 antibody is administered intravenously.
(Item 20)
A method according to any one of the preceding items, wherein said anti-CD47 antibody and/or said anti-PD-L1 antibody is administered intraperitoneally.
(Item 21)
A method according to any one of the preceding items, wherein said anti-CD47 antibody and/or said anti-PD-L1 antibody is administered intratumorally.
(Item 22)
12. The method of any one of the preceding items, wherein administration reduces the level of CA125 in said subject compared to baseline, and optionally said level of CA125 is measured about once a month.
(Item 23)
wherein administration reduces the level of CA125 in said subject by at least 30-90, 40-80, 50-70, 30, 40, 50, 60, 70, 80, or 90% compared to baseline A method according to any one of
(Item 24)
administering decreases the size of the cancer or its metastases, optionally as measured by imaging, compared to baseline, optionally wherein said imaging is CT/PET/CT or MRI, and initially at baseline A method according to any one of the preceding items, optionally comprising diseases that increase in size from but then decrease.
(Item 25)
Any of the preceding items, wherein administration reduces levels of at least one of CA125, HE4 (human epididymal protein 4), CA-72-4, CA-19-9, and CEA compared to baseline or the method according to item 1.
(Item 26)
12. The method of any one of the preceding items, further comprising administering a priming dose of an anti-CD47 antibody.
(Item 27)
A method according to any one of the preceding items, further comprising administering a priming dose of an erythropoietin stimulant.
(Item 28)
27. The method of any of items 26, wherein said anti-CD47 antibody is administered to said subject as a priming dose of antibody ranging from about 0.5 to about 5 mg/kg antibody, optionally 1 mg/kg antibody.
(Item 29)
wherein said anti-CD47 antibody ranges from about 20 to about 67.5 mg/kg antibody, optionally 20 mg/kg antibody, 30 mg/kg antibody, 45 mg/kg antibody, 60 mg/kg antibody, or 67.5 mg 12. The method of any one of the preceding items, wherein the subject is administered as a dose of antibody/kg of antibody.
(Item 30)
The method of any one of the preceding items, wherein said anti-CD47 antibody is administered to said subject every week, every two weeks, or every three weeks.
(Item 31)
(a) administering a priming dose of said anti-CD47 antibody to said subject, wherein said priming dose is from about 0.5 to about 5 mg/kg of antibody; and
(b) administering a therapeutically effective dose of said anti-CD47 antibody to said subject at least about 3-14 days after the initiation of step (a), optionally 7 days after (a); , the method of any one of the preceding items.
(Item 32)
(a) administering said priming dose of anti-CD47 antibody to the subject at a dose of 1 mg/kg of antibody on day 1; and (b) administering said therapeutically effective dose of anti-CD47 antibody on day 8 32. The method of item 31, comprising administering to the subject at a dose of 20 mg/kg antibody, 30 mg/kg antibody, 45 mg/kg antibody, 60 mg/kg antibody, or 67.5 mg/kg antibody to the eye. the method of.
(Item 33)
33. The method of any one of items 26-32, wherein the efficacy of the priming dose is determined based on the anemic status of the subject after administration of the priming dose.
(Item 34)
said subject has a reduction in hemoglobulin levels of 8.0 g/dL or greater; and/or
33. The method of any one of items 26-32, wherein the priming dose is considered effective if the subject's absolute reduction in hemoglobin level is less than 3.0-3.75 g/dL.
(Item 35)
32. The method of item 31, further comprising, after step (a) and before step (b), determining whether administration of said priming dose was effective.
(Item 36)
If said determining step comprises performing a reticulocyte count, and said reticulocyte count is between about 100×10 9 ^{reticulocytes} per L and about 1000×10 ⁹ reticulocytes per L, then said priming dose of 36. The method of item 35, wherein the administration is determined to be effective.
(Item 37)
37. The method of claim 36, wherein said determining step comprises performing a reticulocyte count, wherein it is determined that administration of said priming dose was effective if the percentage of reticulocytes in the blood is greater than about 1.5%. Method.
(Item 38)
37. The method of item 36, wherein said determining step comprises performing a reticulocyte count, and wherein it is determined that administration of the priming agent was effective if the reticulocyte index is greater than about 2%.
(Item 39)
39. The method of any one of items 31-38, wherein the priming dose is administered to the human subject as an infusion comprising an anti-CD47 antibody at a concentration of about 0.05 mg/ml to about 0.5 mg/ml. .
(Item 40)
40. The method of item 39, wherein the infusate is delivered over a period of at least about 1-3, 8-10, 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 hours.
(Item 41)
40. The method of item 39, wherein the infusate is delivered over a period of at least about 3 hours.
(Item 42)
40. The method of item 39, wherein the infusate is delivered over a period of about 2.5 hours to about 6 hours.
(Item 43)
39. The method of any one of items 31-38, wherein the priming dose is delivered by a continuous pump over a period of about 6 hours to about 3 days.
(Item 44)
44. The method of any one of items 31-43, wherein the priming dose is delivered subcutaneously.
(Item 45)
45. The method of any one of items 31-44, wherein the priming dose saturates at least about 50% to 100% of the CD47 sites on erythrocytes, optionally 100% of the CD47 sites on erythrocytes.
(Item 46)
said dose is
a receptor occupancy assay in which a blood sample is obtained after administration of a dose of an unlabeled anti-CD47 antibody to a subject and combined with a saturating dose of a detectably labeled anti-CD47 antibody; and
Determining the level of binding
46. The method of item 45, wherein the method is determined by
(Item 47)
The therapeutically effective dose of (b) is sufficient to achieve a circulating level of the anti-CD47 antibody of greater than 100, 250, 500, or 1000 μg/ml for a sustained period of time; 47. The method of any one of items 31-46, wherein the time period is at least 1-28 days, 7-28 days, 7-21 days, 14-28 days, or 21-28 days.
(Item 48)
48. The method of item 47, wherein said duration is about 1, 2, 3, or 4 weeks.
(Item 49)
The method of items 31-48, wherein said priming dose is 1 mg/kg of anti-CD47 antibody.
(Item 50)
The method of items 31-48, wherein the therapeutically effective dose of said anti-CD47 antibody is 20 mg/kg.
(Item 51)
The method of items 31-48, wherein the therapeutically effective dose of said anti-CD47 antibody is 30 mg/kg.
(Item 52)
The method of items 31-48, wherein the therapeutically effective dose of said anti-CD47 antibody is 45 mg/kg.
(Item 53)
The method of items 31-48, wherein the therapeutically effective dose of said anti-CD47 antibody is 60 mg/kg.
(Item 54)
49. The method of items 31-48, wherein the therapeutically effective dose of said anti-CD47 antibody is 67.5 mg/kg.
(Item 55)
55. The method of any one of items 31-54, wherein a therapeutically effective dose of said anti-CD47 antibody is administered about every 7, 14, 21, or 28 days.
(Item 56)
56. The method of any one of items 31-55, wherein a therapeutically effective dose of said anti-CD47 antibody is administered every 7 days.
(Item 57)
A method according to any one of the preceding items, wherein the therapeutically effective amount of said anti-PD-L1 antibody is 10 mg/kg.
(Item 58)
58. The method of item 57, wherein said anti-PD-L1 antibody is administered every 14 days.
(Item 59)
A composition comprising an anti-CD47 antibody and an anti-PD-L1 antibody.
(Item 60)
A kit comprising an anti-CD47 antibody, an anti-PD-L1 antibody, and instructions for use.

DETAILED DESCRIPTION Methods are provided for treating ovarian cancer or reducing the size of ovarian cancer in a subject, the treatment comprising administering an anti-CD47 antibody and an anti-PD-L1 antibody to the subject.

Before the active agents and methods of the present invention are described, this invention is not limited to the particular methodology, products, devices and agents described, and such methods, devices and formulations are, of course, subject to variation. It should be understood that It should also be understood that the terminology used herein is for the purpose of describing particular embodiments only and is not intended to limit the scope of the invention, which is limited solely by the appended claims. .

As used in this specification and the appended claims, the singular forms "a, an (indefinite article)" and "this: (the) (indefinite article)" It should be noted that it includes plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "drug candidate" refers to one or a mixture of such candidates, reference to "method" includes reference to equivalent processes and methods known to those skilled in the art, and the like.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. All publications mentioned herein are incorporated herein by reference for the purpose of describing and disclosing the devices, formulations and methodologies described in the publications and which may be used in connection with the presently described invention. incorporated into.

Where a range of values is provided, each intervening value is up to tenths of the unit below, between the upper and lower limits of the range, and any other value, unless the context clearly indicates otherwise. or the intervening values of the stated ranges are understood to be included within the scope of the invention. The upper and lower limits of these smaller ranges may independently be included in the smaller ranges and are encompassed within the invention, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding any of both of those included limits are also included in the invention.

In the following description, numerous specific details are set forth in order to provide a more thorough understanding of the invention. It will be apparent, however, to one skilled in the art that the invention may be practiced without one or more of these specific details. In other instances, features and procedures well known to those skilled in the art have not been described to avoid obscuring the invention.

In general, conventional methods of protein synthesis, recombinant cell culture and protein isolation, as well as recombinant DNA techniques within the skill of the art are used in the present invention. Such techniques are explained thoroughly in the literature, see, for example, Maniatis, Fritsch & Sambrook, Molecular Cloning: A Laboratory Manual (1982); Sambrook, Russell and Sambrook, Molecular Cloning: A Laboratory Manual. (2001); , Lane and Harlow, Using Antibodies: A Laboratory Manual: Portable Protocol No. I, Cold Spring Harbor Laboratory (1998); and Harlow and Lane, Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory; (1988).

Definitions As used herein, an "anti-CD47 antibody" refers to any antibody that reduces the binding of CD47 (eg, on a target cell) to SIRPα (eg, on phagocytic cells). Non-limiting examples are described in more detail below and include, but are not limited to Hu5F9-G4.

As described in more detail below, an anti-PD-L1 antibody is an antibody that inhibits the binding of PD-L1 (PD1 ligand) to PD1 (programmed death 1). Yes, examples include avelumab.

As used herein, "antibody" includes reference to immunoglobulin molecules that are immunologically reactive with a specific antigen, and includes both polyclonal and monoclonal antibodies. The term also includes genetically engineered forms such as chimeric antibodies (eg, humanized murine antibodies) and heteroconjugate antibodies. The term "antibody" also includes antigen-binding forms of antibodies, including fragments with antigen-binding ability (eg, Fab', F(ab') ₂ , Fab, Fv, and rIgG). The term also refers to recombinant single-chain Fv fragments (scFv). The term antibody also includes bivalent or bispecific molecules, diabodies, triabodies and tetrabodies. Additional details on the term antibody are provided below.

A "patient" for the purposes of the present invention includes both humans and other animals, particularly mammals, including companion animals and laboratory animals such as mice, rats, rabbits, and the like. Thus, this method is applicable to both human therapy and veterinary applications. In one embodiment, the patient is a mammal, preferably a primate. In other embodiments, the patient is human.

The terms "subject," "individual," and "patient" are used interchangeably herein and refer to a mammal being evaluated and/or being treated for treatment. In one embodiment, the mammal is human. The terms "subject," "individual," and "patient" include, without limitation, individuals with cancer. A subject can be a human, but also includes other mammals, particularly mammals useful as experimental models of human disease, such as mice, rats, and the like.

As used herein, the phrase “platinum-sensitive” refers to human subjects who develop recurrent disease more than 6 months after receiving their last platinum-based chemotherapy.

As used herein, the phrase "platinum resistant" refers to human subjects who develop recurrent disease less than 6 months after receiving their last platinum-based chemotherapy.

As used herein, the term "baseline" is defined as the 30-day period prior to administration of the first treatment to a human subject with ovarian cancer.

The term "sample" with respect to a patient includes blood and other liquid samples of biological origin, solid tissue samples such as biopsy specimens or tissue cultures, or cells derived therefrom and their progeny. The definition also includes samples that have been manipulated in any way after procurement, such as treatment with reagents; washed; or subjected to enrichment for particular cell populations, such as cancer cells. This definition also includes samples that are enriched for particular types of molecules, such as nucleic acids, polypeptides, and the like. The term "biological sample" includes clinical samples, tissue obtained by surgical resection, tissue obtained by biopsy, cells in culture, cell supernatants, cell lysates, tissue samples, Also included are organs, bone marrow, blood, plasma, serum, and the like. A "biological sample" includes a sample obtained from a patient's cancer cells, e.g., a sample containing polynucleotides and/or polypeptides obtained from a patient's cancer cells (e.g., polynucleotides and/or cell lysates or other cell extracts containing peptides); as well as samples containing cancer cells from patients. A biological sample containing cancer cells from a patient can also include non-cancerous cells.

The term "diagnosis" is used herein to refer to identification of a molecular or pathological state, disease or condition, such as identification of molecular subtypes of breast cancer, prostate cancer, or other types of cancer. be.

The term "prognosis" is used herein to refer to the prediction of the likelihood of death or progression due to cancer, including recurrence, metastatic spread, and drug resistance of neoplastic diseases such as ovarian cancer. be. The term "prediction" is used herein to refer to the act of predicting or estimating based on observation, experience, or scientific reasoning. In one example, a physician may predict a patient's chances of survival after surgical removal of the primary tumor and/or after a period of chemotherapy without the cancer returning.

As used herein, the terms "treat, treatment," "treatment, treating," and the like refer to the administration of drugs or procedures for the purpose of obtaining an effect. means to carry out. This effect can be prophylactic, with respect to completely or partially preventing the disease or symptoms thereof, and/or therapeutic, with respect to partially or completely curing the disease and/or symptoms of the disease. . As used herein, "treatment" may include treatment of tumors in mammals, particularly humans, including: (a) the disease or symptoms of the disease are associated with the disease occurring in subjects who may be susceptible to , but have not yet been diagnosed with the disease (including, for example, diseases that may be associated with or caused by a primary disease) (b) inhibiting the disease, ie halting its development; and (c) alleviating the disease, ie causing regression of the disease.

Treatment refers to objective or subjective parameters, such as alleviation; remission; alleviation of symptoms or making the disease state more tolerable to the patient; slowing the rate of degeneration or decline; may refer to an indication of success in treating or ameliorating or preventing cancer, including preventing debilitating cancer. Treatment or amelioration of symptoms may be based on objective or subjective parameters, including results of examination by a physician. Accordingly, the term "treating" includes administration of a compound or agent of the invention to prevent or delay, alleviate, or prevent or inhibit the onset of symptoms or conditions associated with cancer or other diseases. The term "therapeutic effect" refers to the reduction, elimination, or prevention of a disease, a symptom of a disease, or a side effect of a disease in a subject.

"In combination with," "combination therapy," and "combination product," in certain embodiments, refer to the simultaneous administration of the agents described herein to a patient. When administered in combination, each component can be administered at the same time or sequentially in any order at different times. Thus, each component can be administered separately but sufficiently close in time to provide the desired therapeutic effect.

"Co-administration" of active agents in the methods of the present invention means administration with the agents at a time such that the agents have a therapeutic effect at the same time. Such concomitant administration may involve simultaneous (ie, simultaneous), prior, or subsequent administration of the agents. A person of ordinary skill in the art would have no difficulty determining the appropriate timing, sequence and dosage of administration for particular drugs and compositions of the present invention.

As used herein, the terms "correlate" or "correlate with" and like terms refer to a statistical association between instances of two events, where the events include numerical values, data sets, and the like. For example, if the events involve numbers, a positive correlation (also referred to herein as a "direct correlation") means that if one increases, the other increases as well. A negative correlation (also referred to herein as an "inverse correlation") means that as one increases the other decreases.

"Dosage unit" refers to physically discrete units suited as unitary dosages for the particular individual to be treated. Each unit may contain a predetermined quantity of active compound(s) calculated to produce the desired therapeutic effect(s) in combination with the required pharmaceutical carrier. Dosage unit form specifications combine (a) the unique characteristics of the active compound(s) and the particular therapeutic effect(s) to be achieved, and (b) such active compound(s). may be determined by technology-specific limitations.

By "therapeutically effective amount" is meant an amount that, when administered to a subject to treat a disease, is sufficient to effect treatment of that disease.

Methods of Treatment Methods are provided for treating a human subject with ovarian cancer or reducing the size of ovarian cancer, comprising administering to the subject an anti-CD47 antibody and an anti-PD-L1 antibody. including. Such methods include, but are not limited to, administering to a subject in need of treatment a therapeutically effective amount or dosage of a combination of the invention in combination with an ESA.

Anti-PD-L1 antibodies can enhance the efficacy of anti-CD47 antibodies. Anti-CD47 antibody combined with or administered prior to anti-PD-L1 antibody to stimulate priming of tumor-specific T cells that can be developed when the inhibitory anti-PD1/PD-L1 pathway is blocked You may

Combinations of anti-CD47 antibodies and anti-PD-L1 antibodies described herein are given to patients with tumor subtypes that respond to these treatments. As described herein, these tumors can be defined by a higher frequency of mutations, resulting in more tumor antigens and thus more immunogenic. In some embodiments, patients treated with combination therapy are responsive to treatment with an immune stimulator or checkpoint inhibitor; It represents a subset of about 25% of patients. In some embodiments, the individual may be platinum therapy sensitive or resistant.

In some embodiments, the methods of the invention comprise administering a priming agent to the subject, followed by administering a therapeutically effective dose of an anti-CD47 antibody and an anti-PD-L1 antibody to the subject. In some embodiments, administering a therapeutically effective dose is at least about 3 days (e.g., at least about 4 days, at least about 5 days, at least about 6 days, at least about 7 days, at least about 8 days, at least about 9 days, or at least about 10 days). This period of time is sufficient, for example, to provide enhanced reticulocyte production by the individual.

Administration of therapeutically effective doses of anti-CD47 and/or anti-PD-L1 antibodies can be accomplished in a number of different ways. In some cases, two or more therapeutically effective doses are administered after the priming agent is administered. Suitable administration of a therapeutically effective dose may involve administration of a single dose, or may involve administration daily, semi-weekly, weekly, biweekly, monthly, yearly, etc. . In some cases, a therapeutically effective dose is administered as two or more doses of increasing concentration (i.e., escalating doses), where (i) all doses are therapeutic doses, or (ii) ) a sub-therapeutic dose (or two or more sub-therapeutic doses) is given initially, and the therapeutic dose is achieved by said stepwise escalation. As one non-limiting example to illustrate increasing concentrations (i.e., increasing doses), the therapeutically effective dose is administered weekly starting with a sub-therapeutic dose (e.g., a dose of 5 mg/kg). and each subsequent dose may be increased by specific increments (e.g., 5 mg/kg increments) or variable increments until a therapeutic dose (e.g., 30 mg/kg) is reached, at which point administration may be discontinued or continued (eg, a continuous therapeutic dose, eg, a dose of 30 mg/kg). As another non-limiting example to illustrate escalating concentrations (i.e., escalating doses), a therapeutically effective dose may be administered weekly starting with a therapeutic dose (e.g., a dose of 10 mg/kg), Each subsequent dose may be increased by specific increments (e.g., 10 mg/kg) or variable increments until a therapeutic dose (e.g., 30 mg/kg, 100 mg/ml, etc.) is reached, at which point , administration may be discontinued or continued (eg, continuous therapeutic doses, eg, doses of 30 mg/kg, 100 mg/ml, etc.). In some embodiments, administration of a therapeutically effective dose may be a continuous infusion, and the dose may vary (eg, titrate) over time.

Dosage and frequency may vary depending on the half-life of anti-CD47 and/or anti-PD-L1 antibodies in the patient. One skilled in the art will appreciate that such guidelines are adjusted for the molecular weight of the active agent, e.g., in the use of antibody fragments, in the use of antibody conjugates, in the use of soluble CD47 peptides, etc. deaf. Dosages may also be administered for topical administration, eg intranasally, by inhalation, or eg i. m. (intramuscular), i. p. (intraperitoneal), i. v. (intravenous), s. c. It may be modified for systemic administration such as (subcutaneous).

In certain embodiments of the invention, the anti-CD47 antibody is administered at the first dose over a period and/or concentration where local concentrations of RBCs and drug are high, the likelihood of the hematologic microenvironment is reduced, and optionally is infused into the patient with subsequent doses.

In some embodiments of the invention, the initial dose of anti-CD47 antibody is at least about 2 hours, at least about 2.5 hours, at least about 3 hours, at least about 3.5 hours, at least about 4 hours, at least about 4 hours. Infused over a period of 0.5 hours, at least about 5 hours, at least about 6 hours or more. In some embodiments, this initial dose is infused over a period of about 2.5 hours to about 6 hours; eg, about 3 hours to about 4 hours. In some such embodiments, the dose of drug in the infusate is from about 0.05 mg/ml to about 0.5 mg/ml; such as from about 0.1 mg/ml to about 0.25 mg/ml. .

Methods of the invention also include co-administration of an anti-PD-L1 antibody and an anti-CD47 antibody. In some embodiments, the anti-PD-L1 antibody is avelumab. In some embodiments, the individual receiving treatment is naive to anti-PD-L1 antibodies. The anti-PD-L1 antibody may be administered together with the anti-CD47 antibody or separately, eg by a suitable delivery method eg i. v. (intravenously), i. p. (intraperitoneal), subcutaneous, intratumoral, or intraperitoneal. A therapeutically effective amount of anti-PD-L1 antibody can be about 10 mg/kg. In some embodiments, an anti-PD-L1 antibody can be administered every 14 days. In other embodiments, an anti-PD-L1 antibody may be administered 7 days after a priming dose of anti-CD47 antibody and every 14 days thereafter. In other embodiments, an anti-PD-L1 antibody may be administered with a priming dose of an anti-CD47 antibody and every 14 days thereafter.

Ovarian Cancer Provided herein is a method for treating an individual with ovarian cancer or reducing the size of ovarian cancer in a subject, comprising administering to the subject a therapeutically effective amount of an anti-CD47 antibody and administering to the subject a therapeutically effective amount of at least one anti-PD-L1 antibody.

Examples of ovarian cancer include epithelial ovarian cancer, optionally serous tumor, mucinous tumor, clear cell tumor, endometrioid tumor, transitional cell tumor, Brenner tumor, carcinosarcoma tumor, mixed epithelial tumor, borderline epithelial tumor , undifferentiated carcinoma tumors, fallopian tube tumors, or primary peritoneal tumors.

In some embodiments, the epithelial ovarian cancer is a serous tumor. Ovarian cancer of serous tumors can be determined as low-grade or high-grade by subclassification of histologic analysis. In one embodiment, the individual is platinum chemotherapy sensitive. In another embodiment, the individual is platinum chemotherapy resistant. In some embodiments, the individual is PD-L1 naive.

In some embodiments, the patient has a low mutational burden. In some embodiments, the patient has a high mutation burden. As is known in the art, cancer types can vary with an average or specific degree of mutation, with higher levels of mutation being associated with increased expression of neoantigens. . For example, Vogelstein et al., supra. , (2013). Low mutational burden refers to cancers with an average or specific number of non-synonymous mutations per tumor up to about 10, up to about 20, up to about 30, up to about 40, up to about 50 for an individual tumor. can be of the type A high mutational burden can be a cancer type with more than about 50, more than about 75, more than about 100, more than about 125, more than about 150 non-synonymous mutations per tumor.

In some such embodiments, the cancer is ovarian cancer, but is not so limited. In some such embodiments, the cancer is of a type with a high neoantigen, or mutagenic burden (Vogelstein et al. (2013) Science 339, specifically incorporated herein by reference). (6127):1546-1558). In other embodiments, the cancer is a type of cancer with low neoantigen load. In some such embodiments, the combination therapy of the invention enhances the activity of checkpoint inhibitors. In other embodiments, combination therapy provides a therapeutic response when the individual cancer fails to respond to checkpoint inhibitors alone. In some embodiments, the individual is platinum sensitive. In other embodiments, the individual is platinum resistant.

Cancer The terms "cancer", "neoplasm" and "tumor" are used interchangeably herein and refer to autonomous and unregulated growth resulting in significant loss of control over cell proliferation. Refers to cells that exhibit an abnormal growth phenotype characterized by Cells of interest for detection, analysis, or treatment in the present application include pre-cancerous (eg, benign), malignant, pre-metastatic, metastatic, and non-metastatic cells. Cancers of almost every tissue are known. The phrase "cancer burden" refers to the amount of cancer cells or cancer volume in a subject. Thus, reducing cancer burden refers to reducing the number of cancer cells or the volume of cancer in a subject. As used herein, the term "cancer cell" refers to any cell that is or is derived from a cancer cell, eg, a clone of a cancer cell. Many types of cancer are known to those skilled in the art, including solid tumors such as carcinoma, sarcoma, glioblastoma, melanoma, lymphoma, myeloma, and circulating cancers such as leukemia. Examples of cancer include, but are not limited to, ovarian cancer, breast cancer, colon cancer, lung cancer, prostate cancer, hepatocellular carcinoma, gastric cancer, pancreatic cancer, cervical cancer, ovarian cancer, liver cancer, bladder cancer, urinary tract cancer, thyroid cancer, renal cancer, carcinoma, melanoma, head and neck cancer, and brain cancer.

The "pathology" of cancer includes all phenomena that compromise the health of the patient. This includes, but is not limited to, abnormal or uncontrolled cell proliferation, metastasis, interference with the normal functioning of adjacent cells, release of cytokines or other secreted products at abnormal levels, inflammatory or immune neoplasm, pre-malignancy, malignancy, invasion of surrounding or distant tissues or organs such as lymph nodes, and the like.

As used herein, the terms "cancer recurrence" and "tumor recurrence" and grammatical variations thereof refer to further proliferation of neoplastic or cancerous cells after diagnosis of cancer. Recurrence may occur, particularly when further cancerous cell proliferation occurs in the cancerous tissue. “Tumor spread” also occurs when tumor cells disseminate to local or distant tissues and organs; thus, tumor spread includes tumor metastasis. "Tumor invasion" occurs when tumor growth spreads locally and impairs the function of involved tissues by compressing, destroying, or preventing normal organ function.

As used herein, the term "metastasis" refers to the growth of a cancerous tumor in organs or parts of the body that are not directly connected to the organ of origin. Metastasis is understood to include micrometastasis, which is the presence of undetectable amounts of cancerous cells in organs or body parts not directly connected to the original cancerous tumor organ. Metastasis may also be defined as some step in the process, such as the departure of cancer cells from the original tumor site and the migration and/or invasion of cancer cells to other parts of the body.

Clinical Endpoints The methods described herein result in at least one improved endpoint compared to baseline.

In some embodiments of the invention, administration of an anti-CD47 antibody and/or an anti-PD-L1 antibody is administered to CA125, HE4 (human epididymal protein 4), CA-72-4, CA-19-9, and Decrease levels of cancer markers such as CEA; compared to baseline. In some embodiments, administration of anti-CD47 antibody and/or anti-PD-L1 antibody reduces CA125 in the subject compared to baseline. In some embodiments, the level of CA125 is measured about once a month. In other embodiments, administration reduces the level of CA125 in the subject by at least 30-90, 40-80, 50-70, 30, 40, 50, 60, 70, 80, or 90% compared to baseline. down to CA125 can be measured by immunoassay. CA125 is described by Mongia et al. , Performance characteristics of seven automated CA 125 assays. Am J Clin Pathol. 2006 Jun;125(6):921-7 (incorporated herein by reference for all purposes). In other embodiments, administering decreases the size of the cancer or its metastases, optionally as measured by imaging, compared to baseline, optionally the imaging is CT/PET/CT or MRI. Yes, optionally including disease that initially increases in size from baseline but then decreases.

As used herein, treatment endpoints are given the meanings known in the art and as used by the Food and Drug Administration.

Overall survival, defined as the time from randomization to death from any cause, is measured in the intention-to-treat population. Survival is considered the most reliable cancer endpoint and is usually the preferred endpoint if studies can be conducted to adequately assess survival. This endpoint is accurate, easy to measure, and recorded by date of death. Bias is not a factor in endpoint measurements. Improved survival should be analyzed as a risk-benefit analysis to assess clinical benefit. Overall survival can be assessed in randomized controlled studies. Demonstration of a statistically significant improvement in overall survival can be considered clinically significant and often supports new drug approval if the toxicity profile is acceptable. Advantages of the methods of the invention may include increased overall patient survival.

Tumor assessment-based endpoints include DFS, ORR, TTP, PFS, and time to treatment failure (TTF). Data collection and analysis for these time-dependent endpoints are based on indirect assessments, calculations, and estimations (eg, tumor measurements). Disease-free survival (DFS) is defined as the time from randomization to tumor recurrence or death from any cause. The most frequent use of this endpoint is adjuvant therapy after radical surgery or radiation therapy. DFS may also be an important endpoint when the majority of patients achieve a complete response to chemotherapy.

Objective response rate. ORR is defined for a minimal period of time as the percentage of patients whose tumor size decreased by a predefined amount. Duration of response is usually measured from the time of initial response until demonstration of tumor progression. Generally, the FDA defines ORR as the sum of partial responses and complete responses. Defined in this way, ORR is a direct measure of drug anti-tumor activity and can be evaluated in single-arm studies.

Time to Progression and Progression-Free Survival. TTP and PFS serve as primary endpoints for drug approval. TTP is defined as the time from randomization to objective tumor progression; TTP does not include death. PFS is defined as the time from randomization to objective tumor progression or death. Accurate definition of tumor progression is critical and needs to be carefully detailed in this protocol.

Antibodies The methods described herein include administration of antibody(ies), ie, anti-CD47 antibodies, and in some embodiments, anti-PD-L1 antibodies. As noted above, the term "antibody" includes reference to immunoglobulin molecules that are immunologically reactive with a specific antigen, and includes both polyclonal and monoclonal antibodies. The term also includes genetically engineered forms such as chimeric antibodies (eg, humanized murine antibodies) and heteroconjugate antibodies. The term "antibody" also includes antigen-binding forms of antibodies, including fragments with antigen-binding ability (eg, Fab', F(ab') ₂ , Fab, Fv, and rIgG). The term also refers to recombinant single-chain Fv fragments (scFv). The term antibody also includes bivalent or bispecific molecules, diabodies, triabodies and tetrabodies.

Antibody selection may be based on a variety of criteria, including selectivity, affinity, cytotoxicity, and the like. The phrase "specifically (or selectively) binds" or "is specifically (or selectively) immunoreactive with" an antibody, when referring to a protein or peptide, includes both proteins and other biologics. Refers to a binding reaction that determines the presence of a protein in a heterogeneous population. Thus, under specified immunoassay conditions, a specified antibody will bind to a particular protein sequence at least two times background, more typically 10 to 100 times more than background. Generally, antibodies of the invention bind antigens on the surface of target cells in the presence of effector cells (such as natural killer cells or macrophages). Fc receptors on effector cells recognize the bound antibody.

Antibodies immunologically reactive with a particular antigen are obtained by recombinant methods such as selection of libraries of recombinant antibodies in phage or similar vectors, or by immunizing animals with the antigen or DNA encoding the antigen. may be generated. Methods for preparing polyclonal antibodies are known to those of skill in the art. Alternatively, the antibody may be a monoclonal antibody. Monoclonal antibodies may be prepared using the hybridoma method. In hybridoma technology, a suitable host animal is typically immunized with an immunizing agent to elicit lymphocytes that produce or are capable of producing antibodies that specifically bind the immunizing agent. Alternatively, the lymphocytes may be immunized in vitro. Lymphocytes are then fused with an immortalized cell line using a suitable fusing agent such as polyethylene glycol to form hybridoma cells.

Human antibodies may be generated using various techniques known in the art, including phage display libraries. Similarly, human antibodies may be produced by introducing human immunoglobulin loci into transgenic animals, eg, mice, in which the endogenous immunoglobulin genes have been partially or completely inactivated. Upon challenge, human antibody production is observed, which is very similar to that seen in humans in all respects, including gene rearrangement, assembly, and antibody repertoire.

Antibodies also exist as a number of well-characterized fragments produced by digestion with various peptidases. Thus, pepsin digests the antibody below the disulfide bond in the hinge region to produce F(ab)' ₂ , a dimer of Fabs that are themselves light chains linked by disulfide bonds to _VH - _CHI . Generate. The F(ab)' ₂ can be reduced under mild conditions to break the disulfide bond in the hinge region, thereby converting the F(ab)' ₂ dimer to a Fab'monomer. A Fab' monomer is essentially a Fab with a portion of the hinge region. Although various antibody fragments have been defined upon digestion of intact antibodies, those skilled in the art will appreciate that such fragments can be synthesized de novo chemically or by using recombinant DNA methodology. . Thus, the term antibody, as used herein, refers to antibody fragments generated by the modification of whole antibodies, or antibodies synthesized de novo using recombinant DNA methodologies (e.g., single-chain Fv), or phage Also included are antibodies identified using display libraries.

A "humanized antibody" is an immunoglobulin molecule that contains minimal sequence derived from non-human immunoglobulin. Humanized antibodies include human immunoglobulins (recipient antibodies) in which residues from the recipient's complementarity determining regions (CDRs) have the desired specificity, affinity and capacity, mouse, rat , or with residues from the CDRs of a non-human species (donor antibody) such as rabbit. In some instances, Fv framework residues of the human immunoglobulin are replaced by corresponding non-human residues. Humanized antibodies may also comprise residues which are found neither in the recipient antibody nor in the imported CDR or framework sequences. Generally, a humanized antibody will comprise substantially all of at least one, and typically two, variable domains, in which all or substantially all of the CDR regions correspond to those of a non-human immunoglobulin and the framework All or substantially all of the regions (FR) are FRs of a human immunoglobulin consensus sequence. The humanized antibody optimally also will comprise at least a portion of an immunoglobulin constant region (Fc), typically that of a human immunoglobulin.

Antibodies of interest can be tested for their ability to induce ADCC (antibody-dependent cellular cytotoxicity) or ADCP (antibody-dependent cellular phagocytosis). Antibody-associated ADCC activity can be monitored and quantified by detecting release of label or lactate dehydrogenase from lysed cells, or detection of decreased viability of target cells (eg, annexin assay). Apoptosis assays may be performed by the terminal deoxynucleotidyl transferase-mediated digoxigenin-11-dUTP nick end labeling (TUNEL) assay (Lazebnik et al., Nature: 371, 346 (1994). Cytotoxicity was also determined by Roche Applied. It can be detected directly by detection kits known in the art, such as the Cytotoxicity Detection Kit from Science (Indianapolis, Ind.).

CD47 Antibodies The methods described herein include administration of anti-CD47 antibodies.

CD47 is a ubiquitously expressed transmembrane glycoprotein with a single Ig-like domain and five transmembrane regions, with binding mediated through the NH2-terminal V-like domain of SIRPalpha cells. Functions as a ligand. SIRPalpha is predominantly expressed in myeloid cells, including macrophages, granulocytes, myeloid dendritic cells (DC), mast cells, and their precursors, including hematopoietic stem cells. Structural determinants of SIRPalpha that mediate CD47 binding are described in Lee et al. (2007)J. Immunol. 179:7741-7750; Hatherley et al. (2008) Mol Cell. 31(2):266-77; Hatherley et al. (2007)J. B. C. 282:14567-75; and the role of SIRPalpha cis-dimerization in CD47 binding has been reviewed by Lee et al. (2010) J. B. C. 285:37953-63. Consistent with CD47's role in inhibiting phagocytosis of normal cells, SIRPalpha is transiently upregulated in hematopoietic stem cells (HSCs) and progenitor cells just prior to and during the migratory phase, and that these There is evidence that the level of cellular CD47 determines their probability of being engulfed in vivo.

In some embodiments, the anti-CD47 antibodies of the invention specifically bind to CD47, allowing the binding of CD47 on one cell (e.g., an infected cell) and SIRPα on another cell (e.g., a phagocytic cell). reduce the interaction between In some embodiments, a suitable anti-CD47 antibody does not activate CD47 upon binding. Some anti-CD47 antibodies do not reduce binding of CD47 to SIRPα, and such antibodies may be referred to as "non-blocking anti-CD47 antibodies." Suitable anti-CD47 antibodies that are "anti-CD47 agents" are sometimes referred to as "CD47 blocking antibodies." Non-limiting examples of suitable antibodies include clones B6H12, 5F9, 8B6, and C3 (see, for example, International Patent Publication No. WO 2011/143624, specifically incorporated herein by reference). ). Suitable anti-CD47 antibodies include fully human, humanized or chimeric forms of such antibodies. Humanized antibodies (eg, hu5F9-G4) are particularly useful for human in vivo applications due to their low antigenicity. Similarly, caninized, feline, etc. antibodies are particularly useful for canine, feline, and other species applications, respectively. Antibodies of interest include humanized or caninized, feline, equine, bovine, porcine, etc. antibodies and variants thereof.

In some embodiments, the anti-CD47 antibody comprises a human IgG Fc region, eg, IgG1, IgG2a, IgG2b, IgG3, IgG4 constant regions. In one embodiment, the IgG Fc region is an IgG4 constant region. The IgG4 hinge can be stabilized by the amino acid substitution S241P (see Angal et al. (1993) Mol. Immunol. 30(1):105-108, specifically incorporated herein by reference).

In some embodiments, the anti-CD47 antibody competes with Hu5F9-G4 for binding to CD47. In some embodiments, the anti-CD47 binds to the same CD47 epitope as Hu5F9-G4.

In some embodiments, the methods described herein comprise administration of anti-CD47 antibody Hu5F9-G4. This antibody is described in US Pat. No. 9,623,079, specifically incorporated herein by reference. In some embodiments, the methods described herein provide for sequences (light chain, heavy chain and/or CDRs) that are at least 97%, at least 98%, at least 99% or 100% identical to the sequence of Hu5F9-G4. administration of an anti-CD47 antibody having Table 1 contains the heavy and light chain sequences of the Hu5F9-G4 antibody. CDR regions are shown in bold.

(Table 1)

PD-L1 Antibodies The methods described herein involve administration of anti-PD-L1 antibodies.

PD-L1 (programmed death ligand 1) is the ligand for PD1. Both PD-L1 and PD1 are examples of immune checkpoint proteins. Immune checkpoint proteins are immunosuppressive molecules that act to reduce immune responsiveness to target cells, particularly to tumor cells in the methods of the invention. The endogenous response to tumors by T cells can be dysregulated by tumor cells activating immune checkpoints (immunosuppressive proteins) and inhibiting co-stimulatory receptors (immunostimulatory proteins). A class of therapeutic agents referred to in the art as "immune checkpoint inhibitors" reverses inhibition of the immune response by administering antagonists of the inhibitory signal. Other immunotherapies administer agonists of immune co-stimulatory molecules to increase responsiveness.

Two immune checkpoint proteins are PD1 and PD-L1. A major role of PD1 is to limit the activity of T cells in peripheral tissues during the inflammatory response to infection and to limit autoimmunity. Activation of T cells induces the expression of PD1. Upon engagement of one of its ligands, PD1 inhibits kinases involved in T cell activation. PD1 is highly expressed on T _Reg cells and may promote proliferation in the presence of ligand. As many tumors are highly infiltrated with T _Reg cells, blocking the PD1 pathway may enhance anti-tumor immune responses by reducing the number and/or suppressive activity of intratumoral T _Reg cells.

The two ligands of PD1 are PD1 ligand 1 (PD-L1; also known as B7-H1 and CD274) and PD-L2 (also known as B7-DC and CD273). PD1 ligands are generally upregulated on the tumor cell surface of many different human tumors. In cells from solid tumors, the major PD1 ligand expressed is PD-L1. PD-L1 is expressed on cancer cells and inhibits T cell activation/function through binding to its receptor PD1 on T cells. Therefore, PD1 and PD-L1 blockers can overcome this inhibitory signaling and maintain or restore anti-tumor T-cell function. Anti-CD47 agents can stimulate specific anti-tumor T cell responses (Anti-CD47 antibody-mediated phagocytosis of cancer by macrophages primes an effective anti-tumor T-cell response; Tseng et al., P roc Natl Acad Sci USA. 2013 Jul 2;110(27):11103-8).

PD-L1 is expressed on cancer cells and inhibits T cell activation/function through binding to its receptor PD1 on T cells. Therefore, PD1 and PD-L1 blockers can overcome this inhibitory signaling and maintain or restore anti-tumor T-cell function. However, because PD-L1 is expressed on tumor cells, antibodies that bind and block PD-L1 may also enable ADCP, ADCC, and CDC of tumor cells. Anti-CD47 agents may synergize with targeted monoclonal antibodies to enhance their efficacy in stimulating ADCP and ADCC (anti-CD47 antibodies synergize with rituximab to promote phagocytosis and eradicate non-Hodgkin's lymphoma , Chao et al., Cell. 2010 Sep 3;142(5):699-713.) Therefore, the combination of an anti-PD-L1 agent and an anti-CD47 agent may enhance anti-tumor efficacy. These agents may be administered together (not necessarily on the same days and frequency over the same course of treatment).

Antibodies in current clinical use against PD-L1 include atezolizumab, durvalumab, and avelumab. Avelumab for locally advanced or metastatic urothelial carcinoma with disease progression during or after platinum-containing chemotherapy, or within 12 months of receiving neoadjuvant or adjuvant platinum-containing chemotherapy A human programmed death ligand 1 (PD-L1) blocking antibody containing an active Fc component (Boyerinas, 2015) approved in the US for the treatment of patients. It is also approved for use in adult and pediatric patients 12 years and older with metastatic Merkel cell carcinoma. Avelumab blocks PD-L1/PD-1-mediated inhibition of adaptive immune responses leading to T cell-induced anti-tumor responses.

In some embodiments, the methods described herein comprise administration of an anti-PD-L1 antibody, eg, avelumab. In some embodiments, the methods described herein provide sequences (light chain, heavy chain and/or CDRs) that are at least 97%, at least 98%, at least 99% or 100% identical to the sequence of avelumab. administration of an anti-PD-L1 antibody with Table 2 contains the heavy and light chain sequences of the avelumab antibody.

(Table 2)

Dosage The methods described herein involve administration of a therapeutically effective dose of the composition, ie, a therapeutically effective dose of either an anti-CD47 antibody and an anti-PD-L1 antibody.

As noted above, the composition is administered to the patient in an amount sufficient to substantially eliminate target cells. An amount sufficient to accomplish this is defined as a "therapeutically effective dose," which can result in improved overall survival. Single or multiple doses of the compositions may be administered according to dosage and frequency as needed and tolerated by the patient. The particular dose required for treatment will depend on the condition and history of the mammal and other factors such as age, weight, sex, route of administration, efficacy and the like.

The effective dose of the combination drug of the present invention for the treatment of cancer depends on the means of administration, the target site, the physiological state of the patient, whether the patient is human or animal, other medications administered, and the treatment. depends on many different factors, including whether is prophylactic or therapeutic. Usually, the patient is a human, but non-human mammals, such as companion animals such as dogs, cats, horses, etc., and laboratory mammals such as rabbits, mice, rats, etc., may also be treated. Treatment doses may be titrated to optimize safety and efficacy.

A therapeutically effective dose of an anti-CD47 antibody may depend on the particular agent used, but is generally about 20 mg/kg body weight or more (e.g., about 20 mg/kg or more, about 25 mg/kg or more, about 30 mg/kg or more). about 35 mg/kg or more, about 40 mg/kg or more, about 45 mg/kg or more, about 50 mg/kg or more, or about 55 mg/kg or more, or about 60 mg/kg or more, or about 65 mg/kg or more, or about 70 mg /kg or more), or from about 20 mg/kg to about 70 mg/kg (eg, from about 20 mg/kg to about 67.5 mg/kg, or from about 20 mg/kg to about 60 mg/kg).

In some embodiments, a therapeutically effective dose of anti-CD47 antibody is 20, 30, 45, 60, or 67.5 mg/kg. In some embodiments, a therapeutically effective dose of anti-CD47 antibody is 20-60 mg/kg. In some embodiments, a therapeutically effective dose of anti-CD47 antibody is 20-67.5 mg/kg.

A therapeutically effective dose of an anti-PD-L1 antibody may depend on the particular antibody used, but is usually about 10 mg/kg body weight or more (eg, about 10 mg/kg or more, about 15 mg/kg or more, about 20 mg/kg or more). /kg or more, about 25 mg/kg or more, about 30 mg/kg or more, about 35 mg/kg or more, about 40 mg/kg or more, about 45 mg/kg or more, about 50 mg/kg or more, or about 55 mg/kg or more, or about 60 mg /kg or more, or about 65 mg/kg or more, or about 70 mg/kg or more), or about 10 mg/kg to about 70 mg/kg (eg, about 10 mg/kg to about 67.5 mg/kg, or about 10 mg/kg to about 60 mg/kg).

In some embodiments, the therapeutically effective amount of anti-PD-L1 antibody is 10 mg/kg. In some embodiments, the anti-PD-L1 antibody is administered every 14 days. In some embodiments, the anti-PD-L1 antibody is administered 7 days after the priming dose and every 14 days thereafter. In some embodiments, the anti-PD-L1 antibody is administered on the same day as the priming dose and every 14 days thereafter.

The dose required to achieve and/or maintain a particular serum level of an administered composition is proportional to the amount of time between doses and inversely proportional to the number of doses administered. Therefore, as the frequency of dosing increases, the required dose decreases. Optimization of dosing strategies will be readily understood and practiced by those skilled in the art. Exemplary treatment regimens call for administration once every two weeks or once a month or once every 3-6 months. A therapeutic entity of the invention is typically administered on multiple occasions. Intervals between single dosages can be weekly, monthly or yearly. Intervals can also be irregular as indicated by measuring blood levels of the therapeutic entity in the patient. Alternatively, therapeutic entities of the invention may be administered as a sustained release formulation, in which case less frequent administration is required. Dosage and frequency will vary depending on the half-life of the polypeptide in the patient.

A "maintenance dose" is a dose intended to be a therapeutically effective dose. For example, in experiments to determine a therapeutically effective dose, multiple different maintenance doses may be administered to different subjects. Thus, some of the maintenance doses may be therapeutically effective doses and other maintenance doses may be subtherapeutic doses.

In prophylactic applications, relatively low doses may be administered at relatively infrequent intervals over an extended period of time. Some patients continue to receive treatment for the rest of their lives. Other therapeutic applications may require relatively high dosages at relatively short intervals until progression of the disease is abated or terminated, and preferably until the patient shows partial or complete amelioration of symptoms of disease. There is also The patient may then be given a prophylactic regimen.

In still other embodiments, the methods of the invention comprise treating, reducing or preventing tumor growth, tumor metastasis, or tumor invasion of cancers such as carcinoma, hematological cancer, melanoma, sarcoma, glioma. . For prophylactic applications, the pharmaceutical composition or medicament is administered to a patient susceptible to or otherwise at risk for the disease, e.g. eliminate or reduce the risk of, reduce the severity of, or delay the onset of the disease, of physical and/or behavioral symptoms, its complications and intermediate pathological phenotypes that appear during the development of the disease is administered in an amount sufficient to

Toxicity of the combined agents described herein can be determined by standard pharmaceutical procedures in cell cultures or experimental animals, e.g., _LD50 (dose lethal to 50% of population) or _LD100 (100 % lethal dose). The dose ratio between toxic and therapeutic effects is the therapeutic index. The data obtained from these cell culture assays and animal studies can be used in formulating a range of dosages that are non-toxic for use in humans. The dosage of proteins described herein lies preferably within a range of circulating concentrations that include the effective dose with little or no toxicity. The dosage may vary within this range depending on the dosage form employed and the route of administration utilized. The exact formulation, route of administration and dosage can be selected by the individual physician in view of the patient's condition.

Priming Agents and Priming Doses In some embodiments of the methods described herein, a priming agent is administered prior to administering a therapeutically effective dose of anti-CD47 antibody and anti-PD-L1 antibody to the individual. Suitable priming agents include erythropoiesis stimulating agents (ESAs) and/or priming doses of anti-CD47 antibodies. Following administration of the priming agent, a therapeutic dose of anti-CD47 antibody is administered after allowing an effective period of time to increase reticulocyte production. Administration may be performed according to the methods described in US Pat. No. 9,623,079, specifically incorporated herein by reference.

In some embodiments, administration of a combination of agents of the invention is combined with an effective dose of an agent that increases the patient's hematocrit, such as an erythropoietin stimulant (ESA). Such agents include, for example, Aranesp® (darbepoetin alfa), Epogen® NF/Procrit® NF (epoetin alfa), Omontys ® (pezinesatide), Procrit®, etc. are known and used in the art.

The term "priming dose", as used herein, refers to a therapeutically effective dose of Refers to the dose of anti-CD47 antibody that primes a subject for administration of anti-CD47 antibody. A particular suitable priming dose of anti-CD47 antibody may vary depending on the nature of the antibody used and a number of subject-specific factors (eg, age, weight, etc.). Examples of suitable priming doses of anti-CD47 antibodies include from about 0.5 mg/kg to about 5 mg/kg, from about 0.5 mg/kg to about 4 mg/kg, from about 0.5 mg/kg to about 3 mg/kg, about 1 mg/kg to about 5 mg/kg, about 1 mg/kg to about 4 mg/kg, about 1 mg/kg to about 3 mg/kg, about 1 mg/kg, about 2 mg/kg, about 3 mg/kg, about 4 mg/kg, about 5 mg/kg. In some embodiments, the priming dose is preferably 1 mg/kg.

In some embodiments of the methods described herein, the anti-CD47 antibody is administered to the subject as a priming dose ranging from about 0.5 to about 5 mg/kg of antibody, optionally 1 mg/kg of antibody. be. In some embodiments, the anti-CD47 antibody ranges from about 20 to about 67.5 mg/kg antibody, optionally 20 mg/kg antibody, 30 mg/kg antibody, 45 mg/kg antibody, 60 mg/kg Antibody, or is administered to the subject as a dose of 67.5 mg/kg of antibody.

In some embodiments of the invention, a priming agent is administered prior to administering a therapeutically effective dose of an anti-CD47 antibody to the individual. Suitable priming agents include erythropoiesis stimulating agents (ESAs) and/or priming doses of anti-CD47 antibodies. After administration of the priming agent and a period of time effective for increasing reticulocyte production, a therapeutic dose of anti-CD47 antibody is administered. A therapeutic dose may be administered in a number of different ways. In some embodiments, two or more therapeutically effective doses are administered after the priming antibody is administered. In some embodiments, a therapeutically effective dose of an anti-CD47 antibody is administered as two or more doses of increasing concentrations, or the doses may be equivalent.

Some embodiments of the invention provide an effective priming dose of Hu-5F9G4, wherein the effective priming dose for humans is about 1 mg/kg, such as at least about 0.5 mg/kg up to up to about 5 mg/kg; at least about 0.75 mg/kg up to about 1.25 mg/kg; at least about 0.95 mg/kg up to about 1.05 mg/kg; and at about 1 mg/kg could be.

In some embodiments of the invention, the initial dose of anti-CD47 antibody is at least about 2 hours, at least about 2.5 hours, at least about 3 hours, at least about 3.5 hours, at least about 4 hours, at least about 4 hours. .5 hours, at least about 5 hours, at least about 6 hours or more. In some embodiments, the initial dose is infused over a period of about 2.5 hours to about 6 hours; eg, about 3 hours to about 4 hours. In some such embodiments, the dose of antibody in the infusate is from about 0.05 mg/ml to about 0.5 mg/ml; such as from about 0.1 mg/ml to about 0.25 mg/ml. .

In some embodiments, the priming dose may be delivered via the subcutaneous route by injection, patch, osmotic pump, etc., as is known in the art.

After administration of the priming antibody and allowing a period of time effective for increasing reticulocyte production, a therapeutic dose of anti-CD47 antibody is administered. A therapeutic dose may be administered in a number of different ways. In some embodiments, two or more therapeutically effective doses are administered after the priming agent is administered (eg, on a weekly dosing schedule). In some embodiments, a therapeutically effective dose of an anti-CD47 antibody is administered as two or more doses of increasing concentrations, or the doses may be equivalent.

In other embodiments, the initial dose, e.g., priming dose, of the CD47 binding antibody is administered as a continuous infusion, e.g., as an osmotic pump, delivery patch, etc., and the dose is administered for at least about 6 hours, at least about 12 hours, at least Administered over a period of about 24 hours, at least about 2 days, at least about 3 days. Many such systems are known in the art. For example, the DUROS technology provides a two-compartment system separated by a piston. One of the compartments consists of an osmotic engine specially formulated with an excess of solid NaCl so that it remains present throughout the delivery period, resulting in a constant osmotic gradient. It also consists of a semi-permeable membrane at one end through which water is drawn into the osmotic engine, establishing a large and constant osmotic gradient between the tissue's water and the osmotic engine. The other compartment consists of a drug solution with openings through which the drug is released due to an osmotic gradient. This helps provide site-specific and systemic drug delivery when implanted in humans. A preferred implantation site is a subcutaneous placement on the inside of the upper arm.

After administration of the priming agent and a period of time effective for increasing reticulocyte production, a therapeutic dose of anti-CD47 antibody is administered. A therapeutic dose may be administered in a number of different ways. In some embodiments, two or more therapeutically effective doses are administered after the priming agent is administered (eg, on a weekly dosing schedule). In some embodiments, a therapeutically effective dose of an anti-CD47 antibody is administered as two or more doses of increasing concentrations, or the doses may be equivalent. There is no need to prolong the infusion time as hemagglutination is reduced after the priming dose.

Administration In the methods described herein, compositions, eg, anti-CD47 antibodies and anti-PD-L1 antibodies, are administered to a subject. The compositions may be administered by parenteral, topical, intravenous, intraperitoneal, intratumoral, oral, subcutaneous, intraarterial, intracranial, intraperitoneal, intranasal or intramuscular means. Typical routes of administration are intravenous or intratumoral, although other routes can be effective as well.

In some embodiments, the anti-CD47 antibody and/or anti-PD-L1 antibody is administered intraperitoneally. In some embodiments, the anti-CD47 antibody and/or anti-PD-L1 antibody is administered intravenously. In some embodiments, the anti-CD47 antibody and/or anti-PD-L1 antibody is administered intratumorally. In one embodiment, a priming dose of anti-CD47 antibody is administered and the priming dose is delivered subcutaneously. In some embodiments, the anti-CD47 antibody and the anti-PD-L1 antibody are administered simultaneously. In some embodiments, the anti-CD47 antibody and anti-PD-L1 antibody are administered sequentially.

The active agents are administered within a period of time to produce an additive or synergistic effect on the depletion of cancer cells within the host. Administration methods include, but are not limited to, systemic administration, intratumoral administration, and the like. Anti-CD47 antibodies are typically administered for about 45 days, about 30 days, about 21 days, about 14 days, about 10 days, about 8 days, about 7 days, about 6 days, about 5 days, about 4 days, about 3 days. , about 2 days, about 1 day, or substantially the same day as the anti-PD-L1 antibody. In some embodiments, the anti-CD47 antibody is administered prior to the anti-PD-L1 antibody. In some embodiments, the anti-CD47 antibody is administered after the anti-PD-L1 antibody. Drugs may be considered combined when the administration schedule is such that the serum levels of both drugs are at therapeutic levels at the same time. Administration may be repeated as necessary to deplete the cancer cell population.

Pharmaceutical Compositions The methods described herein involve administration of pharmaceutical compositions comprising anti-CD47 antibodies and/or anti-PD-L1 antibodies.

Typically, compositions are prepared as injectables, either as liquid solutions or suspensions; solid forms suitable for solution in, or suspension in, liquid vehicles prior to injection can also be prepared. . The preparations may also be emulsified or encapsulated in liposomes or microparticles, such as polylactides, polyglycolides, or copolymers, for enhanced adjuvant effect, as discussed above. Langer, Science 249:1527, 1990 and Hanes, Advanced Drug Delivery Reviews 28:97-119, 1997. Agents of the invention may also be administered in the form of depot injection or implant preparations which can be formulated in such a manner as to permit a sustained or pulsatile release of the active ingredient. Pharmaceutical compositions are generally sterile, substantially isotonic, and formulated in full compliance with all Good Manufacturing Practice (GMP) regulations of the U.S. Food and Drug Administration. has been made

Pharmaceutical compositions may be administered in a variety of unit dosage forms depending on the method of administration. For example, unit dosage forms suitable for oral administration include, but are not limited to, powders, tablets, pills, capsules and lozenges. It is recognized that compositions of the present invention should be protected from digestion when administered orally. This is usually accomplished by complexing the molecule with the composition to render it resistant to acid and enzymatic hydrolysis, or by packaging the molecule in suitable resistant carriers such as liposomes or protective barriers. Means of protecting drugs from digestion are well known in the art.

Compositions for administration typically comprise the antibody or other cleaving agent dissolved in a pharmaceutically acceptable carrier, preferably an aqueous carrier. A variety of aqueous carriers may be used, such as buffered saline. These solutions are sterile and generally free of undesirable matter. These compositions may be sterilized by conventional, well known sterilization techniques. The compositions contain pharmaceutically acceptable auxiliary substances as required to approximate physiological conditions, such as pH adjusting and buffering agents, toxicity adjusting agents and the like, for example sodium acetate, sodium chloride, potassium chloride, calcium chloride, sodium lactate, and the like. It's okay. The concentration of active agent in these formulations can vary widely, and is selected primarily based on fluid volume, viscosity, body weight, etc., according to the particular mode of administration chosen and patient needs (e.g. , Remington's Pharmaceutical Science (15th ed., 1980) and Goodman & Gillman, The Pharmacological Basis of Therapeutics (Hardman et al., eds., 1996)).

"Pharmaceutically acceptable excipient" means an excipient that is generally safe, non-toxic, and useful in the preparation of desirable pharmaceutical compositions for veterinary use as well as for human pharmaceutical use. Contains excipients acceptable for use. Such excipients may be solids, liquids, semi-solids, or, in the case of aerosol compositions, gases.

"Pharmaceutically acceptable salts and esters" means salts and esters that are pharmaceutically acceptable and that have the desired pharmacological properties. Such salts include salts that can be formed when acidic protons present in the compounds are capable of reacting with inorganic or organic bases. Suitable inorganic salts include salts formed with alkali metals such as sodium and potassium, magnesium, calcium, aluminum. Suitable organic salts include those formed with organic bases such as the amine bases, eg ethanolamine, diethanolamine, triethanolamine, tromethamine, N-methylglucamine, and the like. Such salts also include inorganic acids such as hydrochloric acid and hydrobromic acid and organic acids such as acetic acid, citric acid, maleic acid, and alkanesulfonic and arenesulfonic acids such as methanesulfonic acid and benzene. Acid addition salts formed with sulfonic acids) are also included. Pharmaceutically acceptable esters include esters formed from carboxy, sulfonyloxy, and phosphonoxy groups present in the compounds, eg, C _1-6 alkyl esters. When two acidic groups are present, the pharmaceutically acceptable salts or esters may be mono-acid mono-salts or esters, or di-salts or esters; When groups are present, some or all of such groups may be salified or esterified. Compounds named in the present invention may exist in non-salified or non-esterified forms, or may exist in salified and/or esterified forms, the nomenclature of such compounds being derived from the original ( are intended to include both non-salified and non-esterified) compounds and their pharmaceutically acceptable salts and esters. Also, certain compounds named in the present invention may exist in more than one stereoisomeric form, and naming of such compounds refers to all single stereoisomeric forms of such stereoisomers. and all mixtures (whether racemic or otherwise).

The terms "pharmaceutically acceptable", "physiologically acceptable" and grammatical variations thereof are used interchangeably when referring to compositions, carriers, diluents and reagents, and administration of the composition. It means that the substance can be administered to or on humans without producing undesired physiological effects to the extent that it interferes with

Kits Also described herein are kits containing active agents, such as anti-CD47 antibodies and anti-PD-L1 antibodies, and formulations thereof, and instructions for use. The kit may further comprise at least one additional reagent, eg, chemotherapeutic drug, ESA, and the like. Kits typically include a label indicating the intended use of the contents of the kit. The term label includes any written or recorded material provided on or with the kit, or otherwise associated with the kit.

Sequences In some embodiments, the methods described herein use sequences described herein; Including dosing. The sequences of the administered antibodies can be, for example, at least 95, 96, 97, 98, 99, or 100% identical to the sequences described herein.

The term "percent identity" in the context of two or more nucleic acid or polypeptide sequences can be defined using one of the sequence comparison algorithms described below (e.g., BLASTP and BLASTN or others available to those of skill in the art). algorithm), or two or more sequences or subsequences that have the same specific percentage of nucleotides or amino acid residues when compared and aligned for maximum correspondence, as determined by visual inspection. Depending on the application, the percent "identity" can be over a region of the sequences being compared, eg, over a functional domain, or can be over the entire length of the two sequences being compared.

For sequence comparison, typically one sequence acts as a reference sequence, to which test sequences are compared. When using a sequence comparison algorithm, test and reference sequences are entered into a computer, subsequence coordinates are optionally designated, and sequence algorithm program parameters are designated. The sequence comparison algorithm then calculates the percent sequence identities for the test sequence(s) relative to the reference sequence, based on the specified program parameters.

Optimal alignment of sequences for comparison is described, for example, in Smith & Waterman, Adv. Appl. Math. 2:482 (1981) by the local homology algorithm of Needleman & Wunsch, J. Am. Mol. Biol. 48:443 (1970) by the homology alignment algorithm of Pearson & Lipman, Proc. Nat'l. Acad. Sci. USA 85:2444 (1988), by computerized implementations of these algorithms (Wisconsin Genetics Software Package, Genetics Computer Group, 575 Science Dr., GAP, BESTFIT, FASTA, Madison, Wis.). and TFASTA), or by visual inspection (see generally Ausubel et al., infra).

One example of an algorithm suitable for determining percent sequence identity and sequence similarity is the BLAST algorithm, which is described in Altschul et al. , J. Mol. Biol. 215:403-410 (1990). Software for performing BLAST analyzes is publicly available through the National Center for Biotechnology Information (www.ncbi.nlm.nih.gov/).

Example 1
In Vitro Synergy Experiments ADCC assays are performed using mouse or human NK cells (effectors) and mouse or human cancer cells (target cells). Mouse NK cells are isolated from peripheral blood, bone marrow, or spleen; human NK cells are isolated from peripheral blood. Human cancer cell lines or primary samples are labeled (eg, with chromium or fluorescent dyes) for use as target cells.

NK cells and cancer cells are combined in vitro and co-cultured by the following treatments:
- Vehicle control (e.g., PBS)
● Anti-PD-L1 antibody only (including avelumab)
• anti-CD47 antibody only • anti-CD47 antibody plus anti-PD-L1 antibody ADCC is measured via chromium release assay or flow cytometric cell death assay (eg, Annexin V/DAPI staining). NK cell cytokine (eg IFN-gamma) release is measured by ELISA. Changes in cell death and cytokine release in the presence of checkpoint inhibitors in combination with anti-CD47 are determined compared to monotherapy as described above.

Example 2
In vivo Experimental Protocol Cancer cells are injected into mice via subcutaneous, retroperitoneal, or peripheral blood injection and allowed to engraft. Animals are randomized into four treatment groups.
- Vehicle control (e.g., PBS)
● Anti-PD-L1 antibody only (including avelumab)
● Anti-CD47 antibody only ● Anti-PD-L1 antibody in addition to anti-CD47 antibody

Mice are treated daily, three times a week, twice a week, or once a week with each treatment. Tumor burden is measured by measurement of tumor volume, bioluminescence using labeled cancer cells (eg, luciferase positive cells), and/or analysis of peripheral blood. Mouse overall survival is also determined.

Example 3
Study of Avelumab in Combination with Anti-CD47 Antibody in Ovarian Cancer This is a study of patients with solid tumors and checkpoint-naive ovarian, fallopian tube, and primary peritoneal cancers who had progressed within 6 months of prior platinum chemotherapy. Dose optimization study to evaluate the safety, pharmacokinetics, pharmacodynamics, and antitumor activity of avelumab (MSB0010718C) in combination with CD47 blockade in patients. The primary objective is to assess the safety and efficacy of various combinations with CD47 blockade in a limited set of indications, and to optimize dosing regimens if necessary. First, in this study, the safety and antitumor activity of the anti-PD-L1 monoclonal antibody (mAb), avelumab, was combined with 5F9-G4, a humanized antibody that blocks the interaction between CD47 and SIRPalpha. to evaluate. Secondary objectives included determining the recommended dose of Hu5F9-G4 plus avelumab in patients with solid tumors, investigating the pharmacokinetic (PK) and pharmacodynamic (PD) profile of Hu5F9-G4 in combination with avelumab, Evaluation of the immunogenicity of Hu5F9-G4 as well as the effect of this combination on myeloid cell populations in the tumor microenvironment assessed in sequential tumor biopsies of patients with platinum-resistant ovarian cancer are included.

Primary objective measure: The number of participants with dose-limiting toxicity (DLT) will be monitored for the first 5 weeks of treatment, starting with the first priming dose of Hu5F9-G4. The duration of the first cycle is 5 weeks and subsequent cycles are every 4 weeks. The first tumor response assessment is performed immediately prior to week 10 of treatment (before cycle 3) and then every 8 weeks of treatment (every 2 cycles). All toxicities are graded according to the NCI CTCAE Version 4.03. A DLT is defined as a grade 3 or higher AE assessed as related to study treatment occurring during the 4-week DLT observation period.

Secondary Objective Measurements: In the ovarian cancer cohort, a medically viable tumor biopsy will be obtained in all patients at baseline during screening and after completion of Cycle 2 (±2 weeks). Tumor biopsy is an option for safe-running patients. Screening continues for 30 days prior to the first dose of study drug, during which patient eligibility and baseline characteristics are determined. Efficacy will be assessed using the iRECIST criteria. Treatment with an investigational drug may be continued until unacceptable drug-related toxicity occurs or until disease progression by iRECIST. Patients who experience initial disease progression may continue on study until deemed to have progressive disease by iRECIST if all of the following conditions are met: no exacerbation from their tumor, study treatment No unacceptable or irreversible toxicity associated with , no evidence of clinical deterioration or deterioration in performance status, and no imminent life-threatening complications resulting from tumor growth. After treatment, patients are observed for survival until death, withdrawal of consent, or termination of the study, whichever comes first.

(Table 2)

Example 4
T cell assay Antigen presentation assay. For the in vitro antigen presentation assay, 10 ⁴ macrophages are co-cultured with the same number of DLD1-cOVA-GFP cancer cells in serum-free RPMI medium overnight. The next day, an equal volume of RPMI + 20% FCS is added to the cultures. Peripheral lymph nodes are harvested from OT-I or OT-II TCR transgenic mice and labeled with 0.5 mM CFSE (Molecular Probes). T cells are isolated using biotinylated anti-CD8 or anti-CD4 antibodies, followed by enrichment with anti-biotin magnetic beads (Miltenyi Biotec). 5×10 ⁴ T cells are added to the culture and analyzed on day 3 (for OT-I T cells) or day 4 (for OT-II T cells). For the in vivo antigen presentation assay, 2×10 ⁶ CFSE-labeled OT-I T cells (CD45.2) are adoptively transferred into recipient mice (CD45.1). Macrophages are isolated from co-cultures with cancer cells and injected into the footpads of mice. Popliteal lymph nodes are analyzed on day 4 for CFSE dilution in CD45.2+ cells.

In vivo cell killing assay. Briefly, splenocytes from C57BL/Ka(CD45.1) mice are labeled with 10 uM CFSE (CFSE-high) and 1 uM CFSE (CFSE-low). CFSE-high splenocytes are pulsed in 6-well plates with 1 μM SIINFEKL peptide (SEQ ID NO:5) for 1 hour. Prior to iv transfer, cells are mixed with non-peptide pulsed CFSE-low cells at a 1:1 ratio. To account for variations in the CFSE high/low ratio in the absence of peptide-specific lysis, control mice received CFSE-high splenocytes that had not been pulsed with the SIINFEKL peptide (SEQ ID NO: 5) followed by CFSE-low They were mixed with splenocytes at a 1:1 ratio and transferred into mice. Draining lymph nodes are analyzed after 16 hours. Percent cytotoxicity was calculated as normalized to the ratio of control mice receiving splenocytes not pulsed with SIINFEKL peptide (1-% CFSE ^high /% CFSE ^low ) (SEQ ID NO:5).

tumor challenge. 1×10 ⁶ CD8-rich OT-I T cells are adoptively transferred into recipient C57BL/Ka mice. Macrophages from syngeneic C57BL/Ka mice are co-cultured with DLD1-cOVA-GFP tumors, then separated by magnetic enrichment and injected into mouse footpads. The tumor cell line E. G7 (EL.4 cells expressing chicken OVA cDNA) are used for tumor challenge (ATCC) in mice. 1×10 ⁵ E. G7 cells are injected subcutaneously (s.c.) into the right hind limb of mice at a 1:1 ratio with regular Matrigel. Tumor size is measured daily using fine calipers and volume calculated based on length ^* width ^* height ^* π/6.

T cell proliferation. Mature T cells recognize and respond to antigen/MHC complexes through antigen-specific receptors (TCRs). The most direct consequences of TCR activation are induction of specific protein tyrosine kinases (PTKs), degradation of phosphatidylinositol 4,5-bisphosphate (PIP2), activation of protein kinase C (PKC) and intracellular It is the initiation of signal transduction pathways such as an increase in calcium ion concentration. These early events are transduced to the nucleus and cause clonal expansion of T cells; upregulation of cell surface activation markers; differentiation into effector cells; induction of cytotoxicity or cytokine secretion;

T cell activation is assessed by measuring T cell proliferation upon in vitro stimulation of T cells via antigen or agonistic antibodies to the TCR. This protocol was written as a starting point to examine the in vitro proliferation of mouse splenic T cells and human peripheral T cells stimulated via CD3. Important parameters include cell density, antibody titer, and activation kinetics.

Prepare a 5-10 μg/mL solution of anti-CD3e (145-2C11) in sterile PBS. Calculate the number of wells required for each experimental condition and consider 3 samples for each condition. For example, to coat a 1/2 plate (48 wells) requires 2.6 mL of antibody solution. Dispense 50 μL of antibody solution into each well of a 96-well assay plate. To unstimulated control wells, add 50 μL of sterile PBS. Cover plate tightly with Parafilm™ to prevent sample evaporation and incubate at 37°C for 2 hours or prepare plates the day before and store at 4°C overnight. Immediately before adding cells, remove 50 μL of antibody solution with a multichannel pipettor. Rinse each well with 200 μL of sterile PBS and discard the PBS.

Spleens are harvested, single-cell suspensions prepared under sterile conditions, and resuspended at 10 ⁶ /mL in complete RPMI-1640 in the presence of desired agents, eg, anti-CD47, checkpoint inhibitors, etc. do. Add 200 μL of cell suspension to each well and place in a humidified 37° C., 5% CO 2 incubator. Add soluble anti-CD28 to cells at 2 ug/mL. Incubate for 2-4 days. Cells may be harvested and processed for quantification.

Each publication cited herein is hereby incorporated by reference in its entirety for all purposes.

It is to be understood that this invention is not limited to the particular methodology, protocols, cell lines, animal species or genera, and reagents described, as such may vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only and is not intended to limit the scope of the invention, which is limited solely by the appended claims.

As used herein, the singular forms "a, an (indefinite article)" and "the: the (indefinite article)" indicate that the context clearly indicates otherwise. Includes plural referents unless otherwise specified. Thus, for example, reference to "a cell" includes a plurality of such cells, reference to "a culture" to one or more cultures and equivalents thereof known to those skilled in the art, etc. including. All technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs, unless clearly defined otherwise.

Claims (44)

1. A combination for use in a method of treating a human platinum-resistant subject with epithelial ovarian cancer, said combination comprising an anti-CD47 antibody and avelumab, said method comprising:
(a) administering a priming dose of the anti-CD47 antibody to the subject, wherein the priming dose is 1 mg/kg of the anti-CD47 antibody; administering a therapeutically effective dose to said subject, wherein said therapeutically effective dose of said anti-CD47 antibody is 20-45 mg/kg, and step (b) is performed at least after initiation of step (a); (c) administering avelumab to said subject, wherein the dose of avelumab is 10 mg/kg, and step (c) is performed after 7 days and every 7 days or every 2 weeks thereafter; at least about 7 days after (a) and every 14 days thereafter, wherein said anti-CD47 antibody has a heavy chain sequence of SEQ ID NO:1 and a light chain sequence of SEQ ID NO:2. 2. The combination of claim 1 , wherein said tumor type is determined by histological analysis. 3. The combination of claim 1 or 2 , wherein said subject is anti-PD-L1 antibody naive. A combination according to any one of claims 1 to 3 , characterized in that said anti-CD47 antibody and said avelumab are administered simultaneously or sequentially. The combination according to any one of claims 1-4 , wherein said anti-CD47 antibody and said avelumab are each formulated as a pharmaceutical composition with a pharmaceutically acceptable excipient. Combination according to any one of claims 1 to 5 , characterized in that said anti-CD47 antibody and/or said avelumab are administered intravenously. Combination according to any one of claims 1 to 6 , characterized in that said anti-CD47 antibody and/or said avelumab are administered intraperitoneally. Combination according to any one of claims 1 to 7 , characterized in that said anti-CD47 antibody and/or said avelumab are administered intratumorally. 9. The combination of any one of claims 1-8 , wherein administration reduces the level of CA125 in said subject compared to baseline, and optionally said level of CA125 is measured about once a month. The claim wherein administration reduces the level of CA125 in said subject by at least 30-90, 40-80, 50-70, 30, 40, 50, 60, 70, 80, or 90% compared to baseline. 10. A combination according to any one of 1 to 9 . administering decreases the size of the cancer or its metastases, optionally as measured by imaging, compared to baseline, optionally wherein said imaging is CT/PET/CT or MRI, and initially at baseline A combination according to any one of claims 1 to 10 , optionally including diseases that increase in size from but then decrease. 1- wherein administering reduces levels of at least one of CA125, HE4 (human epididymal protein 4), CA-72-4, CA-19-9, and CEA compared to baseline 1-1.A combination according to any one of clauses 1-1 . Combination according to any one of claims 1 to 12 , characterized in that said combination is administered in combination with a priming dose of an erythropoietin stimulant. 14. Any one of claims 1-13 , wherein the anti-CD47 antibody is administered to the subject as a dose of 20 mg/kg antibody, 30 mg/kg antibody, or 45 mg/kg antibody . A combination described in . The combination according to any one of claims 1 to 14 , characterized in that said anti-CD47 antibody is administered to said subject every week. 16. A combination according to any preceding claim, wherein step (b) is performed 7 days after the initiation of step (a). The method comprises the steps of: (a) administering the priming dose of anti-CD47 antibody to the subject at a dose of 1 mg/kg of antibody on day 1; and (b) the therapeutically effective anti-CD47 antibody. 17. The combination of claim 16 , comprising administering a dose to the subject on day 8 at a dose of 20 mg/kg antibody, 30 mg/kg antibody, or 45 mg/kg antibody . 18. The combination of any one of claims 1-17 , wherein the effectiveness of the priming dose is determined based on the subject's anemic status after administration of the priming dose. If the subject's reduction in hemoglobin level is greater than or equal to 8.0 g/dL; and/or the subject's absolute reduction in hemoglobin level is less than 3.0 to 3.75 g/dL, then the priming dose is A combination according to any one of claims 1 to 17 which is considered effective. 17. The combination of Claim 16 , wherein the method further comprises, after step (a) and before step (b), determining whether administration of the priming dose was effective. If said determining step comprises performing a reticulocyte count, and said reticulocyte count is between about 100×10 ⁹ reticulocytes per L and about 1000×10 ⁹ reticulocytes per L, then said priming dose of 21. The combination of Claim 20 , wherein administration is determined to be efficacious. 22. The method of claim 21 , wherein said determining step comprises performing a reticulocyte count, and wherein it is determined that administration of said priming dose was effective if the percentage of reticulocytes in the blood is greater than about 1.5%. combination of. 22. The combination of claim 21 , wherein said determining step comprises performing a reticulocyte count, and it is determined that administration of the priming agent was effective if the reticulocyte index is greater than about 2%. A combination according to any one of claims 1 to 23 , characterized in that said priming dose is administered to a human subject as an infusion . The claim characterized in that said infusate is delivered over a period of at least about 1-3, 8-10, 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 hours. 24. The combination according to 24 . 25. The combination of claim 24 , wherein said infusate is delivered over a period of at least about 3 hours. 25. The combination of claim 24 , wherein said infusate is delivered over a period of about 2.5 hours to about 6 hours. 24. The combination of any one of claims 1-23 , wherein the priming dose is delivered by a continuous pump over a period of about 6 hours to about 3 days. Combination product according to any one of claims 1 to 28 , characterized in that said priming dose is delivered subcutaneously. 30. The combination of any one of claims 1-29 , wherein the priming dose saturates at least about 50% to 100% of the CD47 sites on erythrocytes, optionally 100% of the CD47 sites on erythrocytes. said dose is
a receptor occupancy assay in which a blood sample is obtained after administration of a dose of an unlabeled anti-CD47 antibody to a subject and combined with a saturating dose of a detectably labeled anti-CD47 antibody; and by determining the level of binding. 31. The combination of claim 30 , determined. The therapeutically effective dose of (b) is sufficient to achieve a circulating level of the anti-CD47 antibody of greater than 100, 250, 500, or 1000 μg/ml for a sustained period of time; 32. A combination according to any preceding claim, wherein the period is at least 1-28 days, 7-28 days, 7-21 days, 14-28 days, or 21-28 days. 33. The combination of Claim 32 , wherein said duration is about 1, 2, 3, or 4 weeks. A combination according to any one of claims 1 to 33 , wherein the therapeutically effective dose of said anti-CD47 antibody is 20 mg/kg. A combination according to any one of claims 1 to 33 , wherein the therapeutically effective dose of said anti-CD47 antibody is 30 mg/kg. A combination according to any one of claims 1 to 33 , wherein the therapeutically effective dose of said anti-CD47 antibody is 45 mg/kg. 37. A combination according to any one of claims 1 to 36 , characterized in that a therapeutically effective dose of said anti-CD47 antibody is administered about every 14 days. 37. A combination according to any one of claims 1 to 36 , characterized in that a therapeutically effective dose of said anti-CD47 antibody is administered every 7 days. 39. A kit for treating a human platinum-resistant subject with ovarian cancer comprising the combination of any one of claims 1-38 and instructions for use in treating a human platinum-resistant subject with ovarian cancer. 1. A composition for use in a method of treating a human platinum-resistant subject with epithelial ovarian cancer, said composition comprising an anti-CD47 antibody, said method comprising:
(a) administering a priming dose of said anti-CD47 antibody to said subject, wherein said priming dose is 1 mg/kg of said anti-CD47 antibody; and (b) treatment of said anti-CD47 antibody. administering to said subject a therapeutically effective dose of said anti-CD47 antibody, wherein said therapeutically effective dose of said anti-CD47 antibody is 20-45 mg/kg; and (c) administering avelumab to said subject , wherein the dose of avelumab is 10 mg/kg, and step (c) comprises step ( at least about 7 days after a) and every 14 days thereafter, wherein said anti-CD47 antibody has a heavy chain sequence of SEQ ID NO:1 and a light chain sequence of SEQ ID NO:2. 1. A composition for use in a method of treating a human platinum-resistant subject with epithelial ovarian cancer, said composition comprising avelumab, said method comprising:
(a ) administering a priming dose of an anti -CD47 antibody to said subject, wherein said priming dose is 1 mg/kg of said anti-CD47 antibody; administering to said subject an effective dose, wherein said therapeutically effective dose of said anti-CD47 antibody is 20-45 mg/kg; and (c) administering avelumab to said subject, wherein the dose of avelumab is 10 mg/kg, and step (c) is performed in step (a) ) and every 14 days thereafter, wherein said anti-CD47 antibody has a heavy chain sequence of SEQ ID NO:1 and a light chain sequence of SEQ ID NO:2. 1. A composition for use in a method of treating a human platinum-resistant subject with epithelial ovarian cancer, said composition comprising an anti-CD47 antibody, said method comprising:
(a) administering a priming dose of said anti-CD47 antibody to said subject, wherein said priming dose is 1 mg/kg of said anti-CD47 antibody; and (b) treatment of said anti-CD47 antibody. administering to said subject a therapeutically effective dose of said anti-CD47 antibody, wherein said therapeutically effective dose of said anti-CD47 antibody is 30 mg/kg; and (c) administering avelumab to said subject, wherein the dose of avelumab is 10 mg/kg, and step (c) is at least about 7 days after step (a). and every 14 days thereafter, wherein said anti-CD47 antibody has a heavy chain sequence of SEQ ID NO:1 and a light chain sequence of SEQ ID NO:2. 1. A composition for use in a method of treating a human platinum-resistant subject with epithelial ovarian cancer, said composition comprising avelumab, said method comprising:
(a) administering a priming dose of an anti-CD47 antibody to said subject, wherein said priming dose is 1 mg/kg of said anti-CD47 antibody; administering to said subject an effective dose, wherein said therapeutically effective dose of said anti-CD47 antibody is 30 mg/kg, and step (b) at least about 7 days after initiation of step (a) and thereafter and (c) administering avelumab to said subject, wherein the dose of avelumab is 10 mg/kg, step (c) being at least about 7 days after step (a) and performed every 14 days thereafter, wherein said anti-CD47 antibody has a heavy chain sequence of SEQ ID NO:1 and a light chain sequence of SEQ ID NO:2. Claims 1-38, wherein a loading dose of said anti-CD47 antibody is administered to said subject, said loading dose being administered twice weekly prior to step (b) at a dose of 20 mg/kg to 67.5 mg/kg. A combination according to any one of claims 39, a kit according to claim 39, a composition according to any one of claims 40-43.